MODULE 4: Surgical Asepsis and Infection Control PDF

MODULE 4: Surgical Asepsis and Infection Control Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 64-99; 244-254 ORNAC Standards 2023: Section 2: Infection Prevention and...

MODULE 4: Surgical Asepsis and Infection Control Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p. 64-99; 244-254 ORNAC Standards 2023: Section 2: Infection Prevention and Control p. 2-1 – 2-58; 2-98 – 2-105, p.4-11 – 4-13 Learning Outcomes Understand surgical asepsis and the operating room environment. Describe aseptic principles to perioperative nursing practice. Understand best practices to prevent Surgical Site Infections. Describe best practices for transmission-based precautions. Classify the types of Surgical Wounds. Surgical Aseptic Principles The operating room (OR) environment is designed to prevent exposure and transmission of extraneous environmental contaminants into the surgical suite. The OR is also designed to preserve the sterility and integrity of surgical supplies and the sterile field. It is essential that OR personnel adhere to aseptic standards and principles in order to prevent or help minimize the risk of surgical site infections (SSIs) and achieve optimal patient outcomes. This module highlights some of the basic practices that are used to preserve and maintain surgical asepsis. Aseptic Environment 1. Doors of the OR should remain closed 2. Air exchange is Positive Pressure in the OR. Air exchange is dependent on the building code and is usually 20 air exchanges every hour (1 exchange every 3 to 4 minutes) 3. Temperature (20 – 23 degrees Celsius); Humidity 30% - 60%. 4. Traffic in and out of the room should be kept to a minimum Establishing the Sterile field 1. Surfaces must be dry and dust-free before placement of sterile pack. 2. Drapes must be impermeable. 3. Working surface is sterile at table level only once your table is set up. Module 3: Aseptic Technique Sterile Set up 1. Items are opened or dispensed at the time needed and not before. 2. All items to be opened are assessed for package integrity; changed chemical indicators (external and internal). If the perioperative nurse is uncertain, the item is considered unsterile. Filters must be in rigid containers. 3. Expiry dates are checked (if applicable). 4. Peel packages are opened carefully to prevent tearing. The sterile boundary is the inner edge of the peel pack. Please note that peel packs cannot be flipped. 5. Large bundles are opened on a flat surface. 6. As per ORNAC: Flipping of supplies shall not be done, including surgical gloves. 7. Items dropped on floor, compressed, torn, or wet are considered contaminated. 8. Sterile items are handled as little as possible to decrease the potential for contamination. 9. If a case is cancelled and the patient is in the room, all opened supplies are discarded. 10. Movement within or around the sterile field must not contaminate the field. Sterile personnel will pass each other by facing one another (“Front to front”) or by turning their back to each other (“Back to back”). 11. Liquids opened and remaining after the case shall be discarded. Recapping is questionable as the inner spout may have become contaminated while the lid is off. 12. When pouring liquids, avoid splashing or reaching over the sterile field. The scrub nurse should set a sterile receptacle at the table’s edge so that the circulating nurse can pour the liquid without contaminating the sterile field. 13. All poured preps, added medications, saline, and water are shown to the scrub nurse before dispensing. Expiry date should be identified. Maintaining Sterile Field 1. Opened sterile set ups are not left unattended 2. Items of doubtful sterility must be considered unsterile. 3. If a sterile barrier is permeated, it must be considered contaminated. This is called strike through. 4. Sterile gowns are considered sterile only in front, from 2 inches below the neck (chest level) to the table level (sterile field) and the sleeves from 2 inches above the elbow to the cuff. The back is never considered sterile. 5. Tables are sterile at table level only. 6. The edges of a sterile instrument enclosure are considered UNSTERILE. 7. Sterile persons touch only sterile items or areas; unsterile persons touch only unsterile items or areas. Module 3: Aseptic Technique  8. Movement around a sterile field must not contaminate it. Circulating persons do not turn their back on the sterile field or walk between sterile areas. 9. Circulating persons/unsterile personal must remain 12 inches (30cm) away from the sterile setup. These are important principles to which all surgical suite practices must adhere. Review ORNAC Standards Section 2 Infection Prevention and Control for a more comprehensive overview. Microbiology Microorganisms are living organisms that include bacteria, fungi, algae, protozoa, and viruses. Bacteria is the most common cause of surgical site infections. This includes: Staphylococci, Streptococci, Enterococci, Pseudomonas, and Clostridia. Healthcare-Associated Infections (HAIs): Infections acquired by patients while they are receiving treatment in a health care setting. Surgical Site Infection (SSI): An infection that develops in the area of the body where the operation took place. SSI develop in in 1 to 3% of surgical patients. Infection Prevention Implement hospital policy and procedures applicable to preventing SSIs. Adhere to routine and transmission-based precautions. Maintain strict aseptic adherence and technique. Prophylactic antibiotics 30 – 60 minutes before surgical incision Routine Practices Hand hygiene Donning and Doffing appropriate PPE (gown, gloves, eye protection, mask) Discard single use equipment Clean environment Module 3: Aseptic Technique Contact, Droplet, and Airborne Precautions Transmission-based precautions are implemented for patients who are known or suspected to be infected by pathogens spread by contact, droplet, or airborne transmission. Routine practices are implemented in addition to the transmission-based precaution(s), which are based on the specific microorganism’s mode of transmission. Contact Droplet Airborne Mode of Occurs when Occurs when Occurs when Transmission microorganisms are respiratory respiratory transferred from microorganisms are microorganisms remain one infected transferred to a suspended in the air individual to another person by mucosal surface of over time. direct or indirect the recipient. contact. Transmission MRSA, VRE Influenza Tuberculosis Based Costridium Dificile Croup Varicella Infection (C.Diff) Pertussis Suddent Acute Hepatitis A and E Bacterial Meningitis Respiratory Wound Infections Mumps and Syndrome (SARS) Rubeolla New emerging respiratory diseases Additional Contact Precaution Droplet Precaution Airborne Precaution Precautions signs on OR Door Signs on OR Door signs on OR Door OR Attire: OR Attire: OR Attire: Gown and gloves Gown, gloves, eye N95 mask, gloves protection, mask Remove all unnecessary (N95 if applicable) Change OR room equipment and pressure to Negative furniture from room Additional Pressure circulating nurse Transfer patient to Strict adherence to outside of the OR essential personnel only isolation room in (runner) to retrieve PACU supplies. Additional circulating Terminal cleaning nurse outside of the OR of the OR after Transfer patient (runner) to retrieve surgery with a mask to supplies. isolation room in Module 3: Aseptic Technique  Schedule the case PACU. Place surgical mask on at the end of the patient during transfer day in a specific Terminal cleaning room, if possible of the OR after OR room should remain surgery vacant for 1-hour post-op to allow for 1 complete Schedule the case air exchange at the end of the day in a specific Terminal cleaning of the room, if possible OR after surgery Schedule the case at the end of the day in a specific room, if possible Module 3: Aseptic Technique  Wound Classifications The wound classification system indicates the extent of microbial exposure or contamination that may predispose a patient to wound infection postoperatively. By properly classifying the wound type, infection control measures can be implemented correctly. Wound Class Examples Clean Wounds (Class I) General Surgery: Hernia Repair Non-infected wound with no signs of Urology: Nephrectomy inflammation. The respiratory, alimentary, and Plastics: Facelifts genitourinary tracts are not entered. The wound edges are closed and can be drained with closed Neurosurgery: Craniotomy wound drainage. Orthopedics: Total Joint Replacements; Arthroscopy Eyes: Cataracts Vascular and Cardiac: AAA repair, Femoral- Popliteal Bypass Clean Contaminated Wounds (Class II) General Surgery: Bowel cases, Cholecystectomy Operative wounds in which the respiratory, Urology: Urethral and Bladder cases alimentary, and genitourinary tracts are entered. There is no sign of infection and no break in Thoracic: Lobectomy aseptic technique. Plastics: Burns Contaminated Wounds (Class III) Penetrating abdominal trauma involving bowel perforation. Open, fresh, wounds such as penetrating trauma or open fractures. Incisions with obvious ineffective signs or gross spillage from the GI tract. Major breaks in aseptic technique such as nonsterile supply/instrument use. Dirty or Infected Wounds (Class IV) Abscess drainage Infected wound including those with obvious Delayed wound closure existing infection or perforated viscera. Module 3: Aseptic Technique  Wound Healing Wound Closure Characteristics Primary Intention Primary intention is normal, uneventful healing of a wound that has been created aseptically. The wound edges are approximated promptly without any tissue loss. Minimal drainage is present. No dead space remains after wound closure. Second Intention (Granulation and Healing occurs through secondary intention Contraction) when there is tissue loss and the wound edges are not approximated. The wound is not closed and is left open for cleaning and packing to allow healing from the inside towards the surface. Granulation tissue fills the tissue defect. Scar tissue is extensive. Third Intention (Delayed Primary Closure) The wound edges are deliberately not approximated for at least 3 days after surgery or injury. The wound may need debridement. Secondary suture line and retention sutures may be required. Module 3: Aseptic Technique Module 3: Aseptic Technique